THE BUFFALO AND FORT ERIE PUBLIC BRIDGE AUTHORITY IS AN AFFIRMATIVE ACTION/EQUAL OPPORTUNITY EMPLOYER (EEO IS THE LAW). QUALIFIED APPLICANTS ARE CONSIDERED FOR ALL POSITIONS WITHOUT REGARD TO COLOR, RACE, RELIGION, SEXUAL ORIENTATION, GENDER, NATIONAL ORIGIN, MARITAL STATUS, FAMILY STATUS, AGE, DISABILITY, VETERAN STATUS AND ANY OTHER PROTECTED STATUS IDENTIFIED BY FEDERAL, STATE OR LOCAL LAW.

As an applicant you may be required to take a needs assessment test. The test would be for skill, knowledge, and ability as it relates to the essential functions of the job. Reasonable accommodations are made for any person with a disability.

Once an offer of employment has been made, I understand and agree that by signing the agreement, my continued employment is contingent upon meeting and maintaining the conditions of employment outlined therein.

I agree to give the Authority two (2) weeks prior notice of resignation.

I understand that a false statement may disqualify me from employment or cause my dismissal.

I hereby declare that the foregoing information is true and complete to my knowledge. I understand that a false statement may disqualify me from employment, or cause my dismissal.

If you decide to engage an investigative consumer reporting agency to report on my credit and personal history, I authorize you to do so. If a report is obtained, you must provide, at my request, the name and address of the agency so that I may obtain from them the nature and substance of the information contained in the report.

Buffalo and Fort Erie Public Bridge Authority (“Authority) is a United States Government contractor subject to Executive Order 11246, which requires United States Government contractors to ensure equal employment opportunity for all persons, without regard to race, color, religion, sex, sexual orientation, gender identity or national origin, and the Vietnam Era Veterans’ Readjustment Assistance Act of 1974 ("VEVRAA"), as amended by the Jobs for Veterans Act of 2002, which prohibits discrimination against protected veterans and requires Government contractors to take affirmative action to employ and advance in employment qualified disabled veterans, recently separated veterans, active duty wartime or campaign badge veterans, and Armed Forces service medal veterans.

As part of the Authority’s affirmative action efforts, we request your cooperation in completing this voluntary identification form which allows us to comply with Government requirements for record keeping and periodic reporting of this data. The information you provide will be treated confidential and will be used only in accordance with Government reporting requirements. Failure to provide the information requested will not subject you to adverse consideration for the position for which you have applied.

Name

Gender

Male

Female

Are you Hispanic or Latino?

No

Yes

Race

American Indian or Alaska Native

Black or African American

Native Hawaiian or Other Pacific Islander

Asian

White

Two or More Races

Veteran Status (categories and definitions below)

I identify as one or more of the classifications of protected veterans

I am not a protected veteran

I choose not to self-identify as a protected veteran

ETHNICITY/RACE

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

American Indian or Alaska Native – A person having origins in any of the original peoples of North or South America (including Central America), and who maintains a tribal affiliation or community attachment.

Black or African American – A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander– A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Two or More Races – A person who identifies with more than one of the above five races.

PROTECTED VETERANS

Disabled Veteran refers to a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under the laws administered by the Secretary of Veterans Affairs or who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty, in the U.S. military, ground, naval or air service.

Active duty wartime or campaign badge veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized, under the laws administered by the Department of Defense.

Armed Forces service medal veteran refers to a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Voluntary Self-Identification of Disability

Why are you being asked to complete this form

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.
Disabilities include, but are not limited to:

• Blindness

• Autism

• Bipolar disorder

• Post-traumatic stress disorder (PTSD)

• Deafness

• Cerebral palsy

• Major depression

• Obsessive compulsive disorder

• Cancer

• HIV/AIDS

• Multiple sclerosis (MS)

• Impairments requiring the use of a wheelchair

• Diabetes

• Epilepsy

• Schizophrenia

• Muscular dystrophy

• Missing limbs or partially missing limbs

• Intellectual disability (previously called mental retardation)

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DON’T HAVE A DISABILITY

I DON’T WISH TO ANSWER

Your Name

Today's Date

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.